NCA Success Story: Advocating Through the Obstacles for a $90,000 Win

Medical billing errors, wrongful denials, and complex claim processes can be financially devastating to clients with complex medical issues and those who support them. National Care Advisors’ expert advocacy and consulting services have helped countless clients resolve the most complex of medical billing challenges, relieving them of the financial and mental burden.

A client was originally referred to National Care Advisors in 2017 for a Special Needs Assessment and case management services. This client had suffered severe, life altering injuries as a child that had left them with permanent physical and neurological disabilities.

In 2023, this client suffered a life-threatening medical emergency and was hospitalized in another state, leading to $90,000 worth of medical bills being erroneously denied by their insurance provider. NCA was notified of the bill 8 months after the date of service and immediately jumped into action to get the situation resolved.

Over the next year and a half, NCA’s Nurse Consultants, Jen and Danielle, worked together on behalf of the client to resolve this wrongful denial. They made numerous phone calls with the medical and insurance providers, completing multiple billing reviews to ensure that the billing was completed correctly. When hurdles arose, such as the medical provider billing the incorrect insurance provider, or the insurance provider claiming that they were outside the window of appeal, Jen and Danielle were able to swiftly address them utilizing their expertise and advocacy skills.

Ultimately, they had to submit a complaint to the Department of Insurance. After a year and a half of consistent follow-ups, complaints and determined advocacy, the bill was accepted and settled by the insurance provider, leaving the client and their family with no patient responsibility.

This client’s case is not unique. It reflects and all-too-common reality of how complex and error-prone our medical billing and insurance systems can be, particularly when a patient undergoes unexpected emergency care. This is where advocacy and expert consulting become invaluable.

Why is professional advocacy so important in cases such as these?

Medical Billing is a specialized language:

Hospitals and insurance providers speak a language of codes, modifiers and narrow windows for appeal. One wrong entry, like billing the wrong state Medicaid as in the case of this client, can instantly trigger denial, regardless of medical necessity. Most families don’t have the tools, training or time to identify and correct these issues.

Appeals Processes Are Intimidating:

Even when patients are aware of the issue, appeal deadlines are tight, and the process is complex by design. In the case of this client, NCA was told multiple times that we were outside the appeal window. Without a consultant who knows how to push back strategically and legally, families are often left believing they have no recourse of action.

Emotional and Mental Load:

Families like that of the client above are already managing significant emotional stress. Expecting them to navigate inter-state billing disputes, regulatory complaints, and months (or years) of follow-up is not realistic. The advocacy that NCA provides relieves that burden so families can focus on care and healing.

Persistence is Powerful, but Time-Consuming:

It took two years of coordinated effort, including formal complaints and dozens of calls, to correct this client’s billing. That level of persistence is difficult for even the most motivated families. Advocates like NCA’s Nurse Consultants bring not only knowledge but also the bandwidth and structure to follow a case to resolution.

Clients Shouldn't Pay for Systemic Mistakes:

Most importantly, families shouldn't be penalized financially for administrative errors they didn’t cause. Yet, without professional intervention, many end up paying huge bills simply because they didn’t know there was another way.

If you, your loved one or client are facing medical billing challenges, including wrongful denials, administrative errors or missed appeal deadlines, National Care Advisors’ Nurse Consultants can step in to provide expert advocacy services leading to the best possible outcome.